Activity Participation Agreement

Please complete one form per child

Activity details (please refer to flyer for more information)

Participant will travel in workers cars to the following activities:

DAY 1 - Monday 28th September, 10AM - 4PM | Port Augusta Fishing & Arid Land Botanical Gardens *

YES - Attending NO - Unable to attend

DAY 2 - Tuesday 29th September, 10AM - 4PM | MOVIE 'Shaun The Sheep, The Beast of Mossy Bottom' & Op Shopping in Clare *

YES - Attending NO - Unable to attend

DAY 3 - Thursday 8th October, 9AM - 7PM | Adelaide Space Discovery Centre & SA Museum | SPOTS ARE LIMITED *

YES - Attending NO - Unable to attend

PARTICIPANT INFORMATION (to be completed by participant or parent/guardian)

Name of Participant *

Date of Birth *

Name of Parent/Guardian *

Address: *

Phone: *

List Allergies or food dietary's (if applicable) *

List medical conditions *

Does the participant have any medication requirements? *

YESNO

If YES, please specify:

Medicare Number *

Is the particiapnt covered by person/family insurance? *

YESNO

I give permission for my child to travel with support staff in Developing UR Life work cars for program-related outings *

YESNO

Additional Information:

Photography & Video Permission

I,

DO DO NOT

give permission for my child's photographs or videos taken as part of it's daily program, to be used now or in the future for the purpose of external communications, including advertising and marketing as well as posted on the service's Social Media account (s) including Facebook, Instagram and website.

I understand I can withdraw the above consent at any time by advising the Nominated Supervisor in writing.

Participation Agreement

I acknowledge that participation in the activity described above involves risks to the participant (named above) (and-to the participants parents or guardians, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, exposure to infec-tious/communicable disease (including COVID-19), bodily injury, death, emotional injury, personal injury, property dam-age, and financial damage. In consideration for the opportunity to participate in the activity described above (the “activity”), the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by Developing Ur Life Service or its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless Developing Ur Life Service for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise. The parent/guardian authorities Developing Ur Life Service to invoice the plan managers/NDIS for service rendered to participants plan, as per the NDIS Guidelines.

Name *

Signature *

Draw signature|Type signatureClear

Date *

If you have any questions or would like more information about the program, please contact us on (08) 8632 9700 or gabrielle@developingurlife.com